FINANCIAL ASSISTANCE PROGRAM

Do you need help paying for your care at Solvista Health? Our Financial Assistance Program may be able to help. Solvista Health wants to make sure that everyone who needs our services can get them. Finances should not be a barrier.

WHO CAN APPLY?

This program is for clients who:

· Don’t have insurance

· Have insurance that only covers a small portion of their care

· Are not eligible for federal programs such as Medicaid, Medicare or other federal programs

· Are in extreme financial need because of large medical bills or other expenses

WHAT SERVICES ARE COVERED?

The Financial Assistance Program can help if you have received any of these services from Solvista Health:

· Emergency services provided by our crisis team

· Medication management services from our psychiatric prescribers

· Therapy including one-to-one, group and family therapy

· Case management

HOW DO I APPLY?

Decisions are made on a case-by-case basis. Please fill out the Financial Assistance Application form on this page. You will need to show proof that you have a financial need. You will need to show receipts, tax forms and other documents listed below. Our business office will make the decision based on your total household income, your number of dependents and any proof of high medical bills. Roommates are not considered a member of your household.

WHAT COUNTS AS INCOME?

Income includes any money you get from the following sources:

· Jobs

· Self-employment (income after taxes)

· Pensions, dividends and interest

· Social security or disability benefits

· Unemployment benefits

· Stipends or income from other sources such as alimony, child support, etc.

WHAT KIND OF PROOF DO I NEED TO SHOW

Financial assistance is decided on a case-by-case basis, so this list is only an example. Your proof of income may be different.

· Pay stubs from jobs

· Bank statements from checking accounts, savings accounts, etc.

· Most recent tax return

· Unemployment benefits statements

· Social security, disability or pension statements or denial letters

· Court orders of child support or alimony showing income

· Anything else you think will help us make a decision

WHEN WILL I KNOW IF I AM ELIGIBLE

Normally, it takes about 4 to 6 weeks to make a decision. To help us make a decision quickly, make sure you provide all the information we need the first time you apply. You can e-mail the documents to insuranceverification@solvistahealth.org or mail the information to: Solvista Health Business Department, 3225 Independence Rd., Canon City, CO, 81212. We will call you when we make our decision.

WHAT IF YOU DENY MY APPLICATION

If we deny your application, you can appeal our decision by writing us a letter and providing us with more information.

WHAT ELSE DO I NEED TO KNOW

If you are a minor client (ages 15 to 18), you can get mental health or addiction services on your own. If you are still living with your parents or another adult guardian, you can apply for the financial assistance program on your own and do not need to show household income, only income you get on your own.

If we learn that any of the information you provided is incorrect or fraudulent, such as lying about the number of your dependents, or not showing all of your income, we reserve the right to terminate the Financial Assistance Program for you.

To learn more, call the Solvista Health business office at 719-276-5475.

Complete the Financial Assistance Application on this page to proceed.